Accompanying the congregations response is a commentary that provides a rationale for its decision and notes three important exceptions: a physical impossibility, such as the unavailability of feeding tubes; the inability of a patients body to assimilate nutrition or hydration; and medical complications from assisted nutrition or hydration.

Both the response and the commentary raise questions about the state of church teaching on this matter. For all patients, including those in a permanent vegetative state, the common Catholic tradition has sought to determine what benefits an intervention would provide and whether the burdens of intervention are proportionate or disproportionate to the expected benefits. It is clear that the provision of artificial nutrition and hydration to a person is based on a technology that works: nutrients and fluids are delivered and the patient generally ingests them. But is that the end of the analysis? Is the end part of an overall plan to return the patient to health, to gain time so that other needed interventions can be made? Or is it simply to keep the patient physically alivethat is, apparently, to maintain biological life for its own sake?

Has the Church Changed Course?

The doctrinal congregations August announcement stands in contrast to a document it released in 1980, the Declaration on Euthanasia. That declaration explains that one can correctly judge whether a treatment is ordinary or extraordinary by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources. The declaration reflects the wisdom of the common Catholic moral tradition, which seeks to determine whether a particular treatment is extraordinary by evaluating its impact on the health and well-being of the patient, others and the general society.

This declaration is also in harmony with the methodology used by Pius XII to determine whether the newly introduced ventilator was ordinary or extraordinary. He defined ordinary in terms of the circumstances of persons, places, the times and the culture and not imposing a grave burden on ones self or another. His answer did not base the analysis on the nature or a classification of the technology itself, as the current analysis by the congregation seems to do. Rather the pope took the common teaching about ordinary and extraordinary means and used this to resolve the case.

According to the current state of medical knowledge, the persistent vegetative state is irreversible; all one can do for such a patient beyond providing basic care is to maintain the biological signs of life. Providing artificial nutrition and hydration, therefore, does not contribute to the patients recovery or necessarily maintain the patients stable condition. In some instancesand these are not rare cases, as the congregations document suggestssuch interventions can harm the patient, given side effects such as infections at the insertion point of the tube, nausea, vomiting and the possibility of the vomitus choking the patient. Some patients occasionally tear out their tubes, and health care providers are required to restrain them physically. Whether this tearing out is done consciously or unconsciously, the tube must be reinserted, often surgically, which exposes the patient to further risks. Well-documented medical literature recounts the harms and burdens associated with tube-feeding.

Such maintenance violates the dignity of the person, because it defines and reduces their personhood solely to terms of biological functioning. It is physical reductionism, a form of materialism that benefits neither them nor society. And the position seems to confer on physical life an almost absolute value.

The Costs of Care

The congregations August commentary claims that providing artificial nutrition and hydration does not involve excessive expense, that it is within the capacity of an average health-care system and does not of itself require hospitalization. (It recognizes that in cases of extreme poverty the provision of A.N.H. may be impossible; hence is not obligatory.)

Still, the insertion of a feeding tube often involves a surgical procedure; minimally it is an outpatient procedure. Once inserted, the tubes must be monitored regularly to prevent infection and to maintain placement during routine care (moving a patient to prevent bed sores, for example). The document seems to assume that since inserting the feeding tube does not require hospitalization and is not of itself excessively expensive, a patient can be cared for at home.

In the United States, however, the vast majority of persons in a permanent vegetative state reside in nursing homes, where a semi-private room (not including most ancillary medical expenses) costs more than $60,000 a year. Most relatives of patients cannot stay at home during the day, even if they want to, in order to care for family members. Nor does everyone have insurance coverage for such patient care. Even for the insured, the cost of coverage and co-payments is significant and complex, since coverage may change annually when employers negotiate contracts with different insurers.

Regardless of the actual dollar expense of providing artificial nutrition and hydration, which is what the congregations commentary focuses on, another question must be addressed: How longhow many years ordecades?is a patient in a permanent vegetative state obligated to undergo tube feeding, in light of the impact on his or her family and the larger community? Could a prolonged duration of A.N.H. make it so burdensome that the treatment is seen then as extraordinary rather than ordinary?

The 1980 Declaration on Euthanasia notes that the refusal of extraordinary treatment is not the equivalent of suicide; on the contrary it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. Consider the social justice dimension of the statement, which asks us to assess the economic impact on the larger society, even in cases that are not considered extreme. Thus, even though an insurance policy might cover all or part of the cost of A.N.H., one may not be obliged to utilize the coverage.

The 2007 commentary seems to misread the 1980 declaration by assuming that the latters discussion of proportionate or disproportionate treatment refers only to means of treatment when death is imminent. This is not the case. The congregations 1980 statement does discuss obligations when death is imminent; but if one reads the entire section where that reference is made, one finds a larger discussion of the general question of ordinary and extraordinary means of treatment and the legitimacy of withdrawing or forgoing extraordinary means of treatment even when death is not imminent.

The common moral tradition of discussion about ordinary and extraordinary means of interventionor the use of proportionate and disproportionate intervention, as the discussion is now framedextends backward from recent papal and other ecclesiastical or magisterial documents to at least the 1500s. The history of this tradition and its development is extremely important in helping to clarify issues such as the use of feeding tubes. The common moral tradition determined whether an intervention was proportionate on a case-by-case basis, independent of the technology, by looking at the effects on the patient, the family and the larger society. The assumption was that the patient, in consultation with physicians and in relation to the circumstances of his or her life, could come to a correct judgment.

Now, by contrast, an authority classifies the intervention by abstract means based on the nature of the technology, independent of its effect on the patient, and determines whether an intervention is proportionate. This could mean that whenever a new technology is introduced, local churches would have to appeal to the Congregation for the Doctrine of the Faith to find out what to do.

The Case of John Paul II

The dispute over the feeding tube used by Pope John Paul II (see Popes Death Drawn Into Euthanasia Debate, by Ian Fisher, The New York Times, 9/18/07) is an example of the kind of debate one is drawn into when the focus of the ethical decision becomes technology instead of the patient. The doctrinal congregations August commentary gives moral priority to technology by submitting the evaluation of benefits to an impersonal biological standard. Such has not been the common moral tradition, which centers attention on the patient and seeks to provide benefits but wisely realizes that the time for cure can pass and that continued technological assistance can become increasingly burdensome. That is the time for ceasing such interventions, increasing basic care of the patient and accompanying him or her on the next phase of the journey to the Lord.

Consider the case of Pope John Paul II. Recall that during several of his hospitalizations he had a feeding tube that was maintained for a time and then removed. During his final hospitalization, no feeding tube was inserted, nor was one mandated. Doing so would have been easy enough: he had a small clinic set up in his bedroom at the Vatican. Perhaps artificial nutrition and hydration was not mandated because John Paul II was not in a permanent vegetative state. But that raises the question, Is the use of A.N.H. mandated in cases other than P.V.S.? If the use of artificial nutrition and hydration is in principle a proportionate means of preserving life, as the August 2007 document notes, then should it not have been provided to the pope? Is the lack of its provision in the popes case an exception? If so, it would be helpful to know the basis of the exception and who made such a determination.

Perhaps the course of John Pauls dying affords moralists an example of how to think through the use of artificial nutrition and hydration in light of the common moral tradition. The decision to forgo A.N.H. is clearly consistent with the analysis and methodology of the common moral tradition, the 1980 statement and previous statements by the Congregation for the Doctrine of the Faith.

Thomas A. Shannon is emeritus professor of religion and social ethics at Worcester Polytechnic Institute in Worcester, Mass.

Comments

STAN DUNDON | 7/12/2008 - 3:31pm

KEEPING CLOSE TO PRINCIPLES By Stanislaus J. Dundon, Ph.D. In his article “At the End of Life” (America, 02/18/08, pp. 9-12) Thomas Shannon offers some significant and strongly “text-oriented” reflections on tubal feeding of patients, with particular attention to those described as being in a “permanently vegetative state.” The manner in which this discussion is carried out may be more important than the practical conclusions in individual cases. In an earlier article in America (06/06/2005) Shannon pointed out the dangers which might follow certain arguments about how to treat Terri Schiavo. These dangers concerned what doctors and hospitals might be afraid to do if the defenders of Schiavo prevailed. In this discussion, however, the dangers might lie in the other direction: what hospitals might feel free to do with patients who are on tubal feeding for prolonged periods As a survivor of GBS, I was completely paralyzed and unable to speak for 93 days. Like Terri Schiavo, my ultimate recovery was doubtful and I was dependent on ANH. Unlike Terri Shaivo, I also required a ventilator in order to breathe. My subsequent ability to run 5 and 10 K foot races is an argument that tubal feeding was appropriate. However, the enormous cost of my treatment might have been raised some serious discussion of the “risks and benefits” of the intervention, especially in that I seemed to be getting continually more ill. One cannot help asking, especially as a Catholic, what are the principles operating here? The various Vatican documents that Shannon parses are efforts to apply unchanging principles to new and changing technologies. A first such Catholic principle is not assigning an “absolute value” to biological life but rather the protection of the sacredness of the life of the innocent human person. The principle is: No deliberate action or omission shall be undertaken whose purpose it is to end the life of the innocent person. (We will leave the discussion of the death penalty aside.) Once that principle is set aside for any reason, innocent life ceases to be sacred, i.e. untouchable. There are many such sacred principles protecting various aspects of the human person whose sanctioned violation will lead, with complete logical consistency, to a ghastly opening of the floodgates of utilitarianism. Their loss of moral untouchability would produce an ugly society and unbearable threats to innocent individuals. Examples of sacred values would be the freedom to reserve one’s sexual faculties only to one’s spouse, the freedom (of children) to mature intellectually and physically in the natural/social order of things, the freedom to bring one’s child to as healthy a birth as possible. None of these are absolute values unless one means by that term “not to be deliberately violated for someone else’s benefit.” A society sanctioning that promising 15 year-old athletes, even with their consent, could be fed steroids so that local football teams would become invincible and or/ the child become rich in spite of serious health risks is the horror of utilitarianism. And to do further “risk-benefit” evaluations of such exploitation to see when it might be defensible is just what utilitarianism is about. An action or omission can be known to be a direct attack, hostile to the continued life of an innocent individual if it is undertaken for the purpose of ending that life and is not ceased until it does so. It is what we call killing. It is not what is reasonably called “letting die” even if the person is already dying if it is undertaken for the purpose of introducing a new cause of death. To introduce a new cause of death, by action or omission, is to kill. And it is possible to kill a dying person. This is obvious if we think of shooting a person in the head who is dying of liver cancer. Persons who are already dying have all the liberties of healthy person to do things which may in fact shorten their lives, including the use<

After reading the original article and one particular letter in response my comment is “God is greater than that”. Specifically I’m referring to statements that seem to equate the church, or the voice of the church, with a minuscule number of unknown functionaries in the Congregation for the Doctrine of the Faith. I’m referring to a section heading in the original article “Has the Church changed course”, and the words “the Church’s new opinion” in one of the letters. Surely the Holy Spirit acts on a larger scale than this; If God’s love encompasses all 7 billion of us there must be a lot of people of good will whose voices are worthy of being heard on end of life care. Judging from Thomas’ position as emeritus professor, and also from a recent tribute by him to Gordon Zahn in the Catholic Peace Voice, he’s probably just a few years younger than my 76. He and I have probably been around a lot longer than most of the men (I wouldn’t expect many women) in the Congregation. I disagree with their views, Thomas seems to disagree also. Certainly our own lifetime efforts to be followers of Jesus and lovers of God, our experience of end of life care issues with our own loved ones or friends, and our own proximity to requiring end of life care, gives our views as much value as that of the people in the Congregation. The March 10 issue of America notes a Vatican sponsored congress on care for the terminally ill, attended by more than 300 participants. Even though the number of attendees is minuscule relative to even just the worlds 1 billion Catholics, the views presented at this meeting could be more fairly called the voice of the church. I suppose that these views were as varied as those of the commentors on Thomas Shannon’s article. Perhaps this is an indication that with God what matters most is that each one of us makes the final decision on end of life care with our greatest measure of love, care and compassion; the wisdom conveyed via the people in the Congregation would be one factor, but not the sole determinant, in our decision for our loved ones and finally for ourselves. But my main point and plea is please cut God a break. Is God’s voice so small that we can imagine a statement by a small group of people, no matter how well intentioned, to be the sum total of God’s word to humanity? Don Rampolla

KEEPING CLOSE TO PRINCIPLES By Stanislaus J. Dundon, Ph.D. In his article “At the End of Life” (America, 02/18/08, pp. 9-12) Thomas Shannon offers some significant and strongly “text-oriented” reflections on tubal feeding of patients, with particular attention to those described as being in a “permanently vegetative state.” The manner in which this discussion is carried out may be more important than the practical conclusions in individual cases. In an earlier article in America (06/06/2005) Shannon pointed out the dangers which might follow certain arguments about how to treat Terri Schiavo. These dangers concerned what doctors and hospitals might be afraid to do if the defenders of Schiavo prevailed. In this discussion, however, the dangers might lie in the other direction: what hospitals might feel free to do with patients who are on tubal feeding for prolonged periods As a survivor of GBS, I was completely paralyzed and unable to speak for 93 days. Like Terri Schiavo, my ultimate recovery was doubtful and I was dependent on ANH. Unlike Terri Shaivo, I also required a ventilator in order to breathe. My subsequent ability to run 5 and 10 K foot races is. an argument that tubal feeding was appropriate. However, the enormous cost of my treatment might have been raised some serious discussion of the “risks and benefits” of the intervention, especially in that I seemed to be getting continually more ill. One cannot help asking, especially as a Catholic, what are the principles operating here? The various Vatican documents that Shannon parses are efforts to apply unchanging principles to new and changing technologies. A first such Catholic principle is not assigning an “absolute value” to biological life but rather the protection of the sacredness of the life of the innocent human person. The principle is: No deliberate action or omission shall be undertaken whose purpose it is to end the life of the innocent person. (We will leave the discussion of the death penalty aside.) Once that principle is set aside for any reason, innocent life ceases to be sacred, i.e. untouchable. There are many such sacred principles protecting various aspects of the human person whose sanctioned violation will lead, with complete logical consistency, to a ghastly opening of the floodgates of utilitarianism. Their loss of moral untouchability would produce an ugly society and unbearable threats to innocent individuals. Examples of sacred values would be the freedom to reserve one’s sexual faculties only to one’s spouse, the freedom (of children) to mature intellectually and physically in the natural/social order of things, the freedom to bring one’s child to as healthy a birth as possible. None of these are absolute values unless one means by that term “not to be deliberately violated for someone else’s benefit.” A society sanctioning that promising 15 year-old athletes, even with their consent, could be fed steroids so that local football teams would become invincible and or/ the child become rich in spite of serious health risks is the horror of utilitarianism. And to do further “risk-benefit” evaluations of such exploitation to see when it might be defensible is just what utilitarianism is about. An action or omission can be known to be a direct attack, hostile to the continued life of an innocent individual if it is undertaken for the purpose of ending that life and is not ceased until it does so. It is what we call killing. It is not what is reasonably called “letting die” even if the person is already dying if it is undertaken for the purpose of introducing a new cause of death. To introduce a new cause of death, by action or omission, is to kill. And it is possible to kill a dying person. This is obvious if we think of shooting a person in the head who is dying of liver cancer. Persons who are already dying have all the liberties of healthy person to do things which may in fact shorten their lives, including the use

Father Sean's argument is logical. Insertion of a feeding tube is a simple procedure to allow nutrition and hydration. But why stop at food? Breathing is necessary and natural! Insertion of a breathing tube to the neck (tracheostomy) is also a simple procedure. Yes, let us have every one with feeding tubes and breathing tubes inserted, whilst we await the next document to emanate from Rome about what else is ordinary and necessary.........

I am disappointed with Fr. Sean's response also both because of its patronizing nature and its misunderstanding of the physiology of the aging body and nutrition and the moral issues involved in this discussion that have been well explained by Thomas Shannon and alluded to in a previous article by John Hardt on "My Father's Choice."

Dear Fr. Sean, I believe that the advice to Kathy is patronizing and medically and morally incorrect. I think that this article and a previous one about "My father's wishes" explains far better how to think of the human process -- not just the physiology --of the human body and spirit as the dying and letting go process begins.

http://www.americamagazine.org/content/contact-us.cfm I read with interest your cover article in your current issue, February 18, 2008, by Thomas a. Shannon, “At the End of Life.” Not only is my mother-in-law in a rehab center with pneumonia, but I am contemplating my own final passage with the experience of the death of both parents and some close friends fresh in my mind. In preparation for this response, I looked in vain in your archives for the personal reflection that appeared since the Congregation for the Doctrine of the Faith published its response to artificial nutrition and hydration back in August 2007. My computer and your website are not on friendly terms. I agree with the conclusions of these recent articles, and I would not request/suggest that you broaden the question to questions of personal freedom, moral choice, and quality of life. In my father’s case it was a question of quality of life. He had been in a nursing home for six years, debilitated by a major stroke. Fluids were leaking into his abdomen, and the doctors outlined a series of surgeries necessary to stabilize his bodily functions. When my mother asked whether he could be brought to a better quality of life, and the doctors said that none of the surgeries would improve his condition, she declined to put him through the trauma of even more pain and prolonged distress. My mother’s case was similar. She had had arthritis from her teen years, and she endured about sixty surgeries for all manner of ailments over the course of her life. When her pain became unbearable yet again, she asked her Catholic doctor to stop trying to prolong her life. Mercifully, he ordered neither resuscitation nor nutrition as she entered her final agony. The entire family was able to make their loving goodbyes before she gave up her spirit. She, in turn, was conscious and able to respond with tender words of love and gratitude for them. This final case happened to a dear friend of thirty years’ standing. Exploratory surgery revealed extensive abdominal cancer that caused a stomach blockage and prevented her from taking nutrition. After consulting with her priest, she declined that surgery and any other procedure that could only extend her life and not cure the cancer. My mother-in-law does not want her children to give up too quickly on her ability to keep on living. At the same time, she has repeatedly stated that she never wanted to spend her life dependent on anyone and unable to take care of herself. She prayed for death. I don’t know if my wife and her siblings will soon have to make life-or-death decisions on her behalf, but I find the guidance of the Church very confusing and impersonal. I am a lifelong Catholic, and I oppose suicide and euthanasia. At the same time, I do not wish to burden my children and/or grandchildren. My only regret in dying would be that my wife is left alone, perhaps for many years given our respective genes. Must I wait for the permanent vegetative state before dispensing with all “ordinary” means of preserving my life?

Although not a theologian, doctor, or hospice caregiver, I have been a primary decision maker for my mother, father, and mother-in-law for end of life medical issues. In all three cases, we came to a unanimous family decision to provide comfort and loving support but not to extend their lives through artificial means. This is what we feel they would have chosen. My parents were both 91. Mom was in the last stages of Alzheimers and Dad was in the last stages of degenerative heart disease. To have inserted a feeding tube at the end of their lives would have been a violation of their dignity. We are first called to compassion. As a special ed teacher, I have had many students that were fed through a tube. They were wonderful little characters and the tube feeding (usually from birth) gave them a chance at life. Many learned to eat "real food". I believe this to be an entirely different situation. By the way, I consider the comment by Father Sean about "younger and sharper commenters" to be unkind. Younger doesn't necessarily mean sharper. Sometimes its the other way around.

As a member of the Medical Ethics Committee at a local community hospital for over ten years, I read with interest this article "At the End of Life" and the recent article in the Feb. 18, 2008 isssue of America "Church Teaching and My Father's Choice". I would concur with the overall tone and conclusions or implied conclusions of both articles. I suspect that the average Catholic in the pew will respond to the Church's new opinion on this topic relating to artifical nutrition and hydration much as he or she has responded to the Church's old opinion relating to the topic of artifical birth control. By and large both opiniions will continue to be mostly ignored.

Dear Kathy, It is distressful to see a loved one, your mother, in the final stages of an incurable illness. You want the long good-bye to end with dignity. She cared for you when you did not want to eat as a baby. Your gums were cutting teeth and she felt helpless too. Feelings are powerful at the moment. You want it all to end, and now. Sometimes however, there are things more important than my subjective feelings at the moment. You never want to have it on your conscience later that the terminal cause of your mother’s death was starvation. Starvation is not a matter of feeling it is an objective reality. Your mother needs food. A simple surgical procedure can make this happen. A tube goes directly into her stomach, not via her mouth as in the old days. It will also end the stress of the spoon feeding. If your mother has a competent old-age psychiatrist the anxiety which your mother is suffering can be brought under control. If not, find a new one quickly. You can be a united family around the bed of your mother. I have no doubt that this too would ease her suffering. Feelings change. The objective reality does not. “I was hungry and you gave me food.” Jesus said. He did not say “If it feels good, it is good.” By his bodily wounds we are healed. Therein we find our dignity.

Dear Kathy, It is distressful to see a loved one, your mother, in the final stages of a long illness. You want the long good-bye to end with dignity. She cared for you when you did not want to eat as a baby. Your gums were cutting teeth and she felt helpless too. Feelings are powerful at the moment. You want it all to end, and now. Sometimes however, there are things more important than my subjective feelings at the moment. You never want to have it on your conscience later that the terminal cause of your mother’s death was starvation. Starvation is not a matter of your feelings it is an objective reality. Your mother needs food. A simple surgical procedure can make this happen. A tube goes directly into her stomach, not via her mouth as in the old days. It will also end the stress of the spoon feeding. If your mother has a competent old-age psychiatrist the anxiety which your mother is suffering can be brought under control. If not, find a new one quickly. You can be a united family around the bed of your mother. I have no doubt that this too would ease her suffering. Feelings change. The objective reality does not. “I was hungry and you gave me food.”

My brothers, sister and I are now facing the decision of the care of our mother in the last stage of her life. She is in a nursing home, she has multiple physical problems including demensia. She is refusing to eat much of the time. Mom will be 90 years old in June. She is confused most of the time , although she does recognize all 6 of her children and on occation some others. She is vey unhappy and can be very aggitated at times. One of my brothers feels that we are not doing enough for her and feels we should consider a feeding tube. The rest of us believe that it is time for God to ease her suffering and take her home. We do not believe we are starving her to death. We feel that her body takes in what nurishment she needs and that it is not for us to force food on her through a tube to sustain a life with little quality. She is hydrated. I truly beleive that this is what we should do. Be near her, love her but we cannot force her to eat. I am at peace with this decision. This is not euthinasia but letting God be God.

I'm reading this article through the haze of having been ill for the past three weeks--four days of it in the hospital with a serious cardiac condition, the rest with diverticulitis. Hardly digesting the in-and-out's of it all (my brain not "up to snuff" yet)I don't see how families and the dying one could even hope to make these kinds of decisions without having already "mapped it out" aforehand--and who can foretell all the various exigencies that might come up when the circumstance is right at hand? It will come down for most to be what feels right at the time, just like it always has been--and dealing with the Church and one's conscience afterward (for the good Lord is there walking with us in this journey one way or the other anyway, and is ALWAYS and forevermore knowing of what it is we have been dealing)!

The issue is not really which medical interventions should be required and which should be optional, but the morality of what we may decide on behalf of another who is unable to communicate with us. The author seems to have missed that as the point of the 2007 statement.

Thomas A. Shannon points out correctly in his closely argued article "At the End of Life," February 18, 2008, that the use of a feeding tube for a person in a persistent vegetative state, which current medical knowledge considers irreversible, "seems to confer on physical life an almost absolute value." My hope is that when the 'dying process' has clearly begun in me, and it becomes clear in me that my physical life is slipping away, and is not, therefore, an absolute value, that my wishes stated in my living will will be respected, and I will be allowed to make the final journey that I have spent my life preparing for. May I be given the final grace to join Francis of Assisi in saying: "Welcome, Sister Death." Fr. Eugene Michel, O.F.M., Pastor of Sacred Heart Church, St. Paul, Minnesota.

I am not often shocked by what I read but this article did it. The language of personhood here is straight out of the 1930's. Also talk of "physical reductionism, a form of materialism" sees human being as basically angels, not the ensouled bodies that we are. The points about nursing home costs could also be applied to Alzheimer patients who need manual assisted feeding. Are we not going to spoon feed advanced cases? Death due to starvation was never an issue in the case of JPII because death came so quickly. Perhaps there are younger and sharper commenters who could better argue a case against the Vatican document than the emeritus professor.